Records management is a critical function for modern organizations. It is a particularly critical function for hospitals and other acute care health facilities where the Medical Records Departments compile the documentation that represents the complete records of a patient's health care administered at that facility. Accurate and complete records are vital to the operation of a hospital for the following reasons.
1. These records contain information required to provide the appropriate health care for patients. PA0 2. These records contain information required for the prompt and accurate billing the patient, and for the appropriate reimbursement of patients in the hospital by third parties such as insurers and government agencies. PA0 3. Medical records are periodically audited by government agencies to review hospital certification, and are also audited to review physicians' credentials. PA0 4. If a claim of malpractice is brought against either the physician, the hospital, or staff members, information in the patient's medical records can have significant judicial implications. PA0 5. Information in medical records is frequently reviewed to determine patients' demographics to plan the availability of future health care services.
For these reasons the accuracy and completeness of patients' medical records is vital, both to the day to day operation and to the strategic planning of a hospital. They are also critical factors considered in granting and renewing hospital certification. Further, in this era of extensive and continuous "cost containment" efforts, it is vital that hospitals promptly and accurately bill patients and third parties while, at the same time exercising the upmost control over their costs.
One approach to these problems in hospitals and other organizations requiring efficient records management functions has been the use of central dictation systems. Such systems may either be analog, such as the system marketed by the assignee of the present Application under the Trademark Nucleus, or digital such as the systems marketed by the assignee of the present Application under the Trademarks DX 2000 and DX 7000. Such systems allow physicians or other professionals to dictate reports for later transcription by a pool of skilled transcriptionists. Document management systems are known and are commercially available to manage and track records, and some of these systems have been customized for medical records applications. However, most of these systems are highly sophisticated and very expensive and are usually only affordable by larger hospitals (350 or more beds).
Systems such as Nucleus and the DX 2000 have been combined with medical records management systems in order to facilitate the generation of "exception reports" indicating those reports which have not been provided by the responsible physician. Due to the delay which sometimes occurs in transcribing of dictated reports, it will frequently happen that a physician will dictate a report, yet receive and have to respond to a request for the report during the time between dictation and transcription. Since physicians tend to resent these intrusions, central dictation systems such as Nucleus and the DX 2000 have been provided with communications links to medical document management systems to inform the document management system as soon as a report is dictated in order to avoid having the document management system generate an inaccurate reception report indicating that the physician is delinquent.
A related problem faced by hospitals is the prompt and accurate generation of "discharge summaries". In order to generate a bill for a patient's stay in a hospital, a discharge summary containing information such as the primary and secondary diagnosis, procedures performed, length of stay, etc. must be prepared, and reviewed, and signed by the patient's physician. At present, many hospitals employ skilled para-professionals for the purpose of reviewing and summarizing a patient's medical record to prepare such summaries when the patient is discharged.
Thus, it is an object of the present invention to provide an improved, cost effective system for record management; and more particularly, medical record management.
It is still another object of the subject invention to provide a system which will increase the efficiency of the transcription of records, and particularly medical records.